Provider Demographics
NPI:1053497628
Name:CHARLES, MARCOS ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCOS
Middle Name:ANTONIO
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARCOS
Other - Middle Name:ANTONIO
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3184 GRAND CONCOURSE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1054
Mailing Address - Country:US
Mailing Address - Phone:718-367-0010
Mailing Address - Fax:718-562-2203
Practice Address - Street 1:3184 GRAND CONCOURSE
Practice Address - Street 2:SUITE 2B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1054
Practice Address - Country:US
Practice Address - Phone:718-367-0010
Practice Address - Fax:718-562-2203
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103040207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00178607Medicaid
NY00178607Medicaid
C10833Medicare UPIN